How one letter led America down the path of opioid addiction

Currently, America is facing its worst drug crisis yet. The origins of the epidemic can be traced back to a single letter in 1980.

That year, research scientist, Dr Hershel Jick and graduate student Jane Porter from Boston University Medical Centre, had penned a one-paragraph letter to the editor the New England Journal of Medicine. The letter, titled Addiction Rare in Patients Treated with Narcotic, spoke briefly on the addiction risk of patients at their hospital.

The authors wrote that out of nearly 40,000 patients given opioids, only four became addicted. It was not a study as there were no objectives or methods that described how the authors determined addiction.

Just how far did the letter go?

Determined to understand what happened, Dr David Juurlink, head of clinical pharmacology and toxicology at Sunnybrook Health Science’s Centre in Toronto, analysed more than 600 citations and references to the letter from its publication till May of this year.

Juurlink said they found that “nearly three-quarters of the citing articles parroted that study's message that addiction was rare, based on nothing on all.”

“It’s difficult to overstate the role of this letter,” Juurlink said.

“It was the key bit of literature that helped the opiate manufacturers convince front-line doctors that addiction is not a concern.”

One citation said, “this pain population with no abuse history is literally at no risk for addiction.” Another said, “there have been studies suggesting that addiction rarely evolves in the setting of painful conditions.”

Drug companies took advantage of the letter

The letter’s author Jick, said, “I’m mortified that that letter to the editor was used as an excuse to do what these drug companies did.”

“They used this letter to spread the word that these drugs were not very addictive.”

He has since gone on record to clarify that his letter only referred to patients hospitalised over a short period of time and not on long-term outpatient use. He also acted as a government witness in a lawsuit over the marketing of pain drugs, many years ago.

The journal’s editor has also spoken out saying, “people have used the letter to suggest that you’re not going to get addicted to opioids if you get them in a hospital setting. We know that not to be true.”

Additionally, the National Institutes of Health in America have pledged to work with the leaders of drug companies, to identify ways to cut in half the amount of time it usually takes to develop new treatments. They hope to discover new, non-addictive drugs for chronic pain, find ways to treat addiction and reverse and prevent overdose.

There has been some justice in the form of a manufacturer of oxycodone and three senior executives pleading guilty to federal criminal charges in America. They agreed that they had misled regulators, doctors, and patients about the risk of addiction when using the drug.

For Juurlink though, this is not enough.

While the risk of addiction from opioids in the real world is not known, Juurlink says that “the best available evidence suggests it's somewhere between five and 10% with long-term therapy.”

However, this “is a staggering number,” he says, “when you think about the millions of people who are on these drugs now." MIMS

At the recent Malaysian Community Pharmacy Business Forum (MyCPBF), a discussion forum was held on the subject of “Transcending Primary Healthcare Services: The Future of Specialized Pharmacy Services and Pharmacy Specialization”.